Provider Demographics
NPI:1760736144
Name:OTT, ROBERT L (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:OTT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 S.E. 179TH AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1035
Mailing Address - Country:US
Mailing Address - Phone:503-761-5610
Mailing Address - Fax:503-761-9072
Practice Address - Street 1:2515 S.E. 179TH AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1035
Practice Address - Country:US
Practice Address - Phone:503-761-5610
Practice Address - Fax:503-761-9072
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR40751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice